title: Outcome study of prehospital patients signed out against medical advice by field paramedics.
abstract: OBJECTIVE
  To describe the incidence and demographic data of prehospital patients who contact paramedics by way of the 911 system, refuse transport against medical advice (AMA), then call 911 and are subsequently reevaluated by paramedics in the following 48 hours.
  
  
  METHODS
  We conducted a retrospective observational review of records using the San Diego County Quality Assurance Network database for prehospital providers. All paramedic 911 responses that made base hospital contact over a 3-month period were reviewed to identify patients who signed out AMA. The main outcome measure was to identify patients who signed out AMA and then called 911 again within 48 hours. The demographics, complaints, treatments, and dispositions of these patients are described.
  
  
  RESULTS
  Of 6,512 total 911 responses reviewed, 443 (7%) involved patients who signed out AMA. Of these patients, 156 cases (35.2%) were listed as trauma and 287 (64.8%) were medical, with cardiac chest pain, seizure, and respiratory distress/shortness of breath the most frequently noted medical subcategories. Fifty-one (11.5%) such patients received treatment; 34 received dextrose, 12 naloxone, 4 albuterol, and 1 a splint. Patient names were available in 5,515, of the total 6,512 responses and 431 of the 443 AMA cases, permitting computer searching of reevaluations by paramedics. Of the 431 AMA patients for whom a name was available, 10 (2%) called 911 again within 48 hours. All 10 callbacks were made for a related chief compliant, and all 10 of these patients were transported (4 admitted to hospital, 1 died en route, 1 transferred to another facility, 4 discharged from the ED). Of these 10 patients, 7 (70%) were older than 65 years, compared with 17% of all AMA patients older than 65 years.
  
  
  CONCLUSIONS
  On the basis of our findings, patients over the age of 65 years have a propensity to recontact paramedics and should be aggressively encouraged to seek emergency medical treatment. Future prospective studies should be mounted to examine at patient outcome and to assess why patients sign out AMA after making contact with paramedics.
authors.affiliation: Department of Emergency Medicine University of California, San Diego, Medical Center 92103, USA.
authors.forename: S T
authors.initials: ST
authors.lastname: Moss
authors.forename: T C
authors.initials: TC
authors.lastname: Chan
authors.forename: J
authors.initials: J
authors.lastname: Buchanan
authors.forename: J V
authors.initials: JV
authors.lastname: Dunford
authors.forename: G M
authors.initials: GM
authors.lastname: Vilke
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D004632:Emergency Medical Services / Q000706:statistics & numerical data*; D004634:Emergency Medical Technicians; D005260:Female; D006304:Health Status; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D016312:Treatment Refusal / Q000706:statistics & numerical data*